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It's starting to 'come together'....


It's starting to come together, I think...thank God for that. I'm in second semester, and I have a rocking professor and clinical group/assignment. It's tough, but I'm lovin' it. But on Wednesday, I could feel things clicking in my head, and I was putting things together like I've never put them together before...

My pt had been in for several weeks, a shunt placed in her liver; she had ARF, HTN, cirrhosis, and Hep C as co-diagnoses. I pulled her labs before I saw her, and her K+ was over 6, BUN at 60, low platelets, low H&H, and BP last two vs were 90s/40s, satting at 100 w/O2. She had had a transfusion of PRBCs the day before. She scared me a lot...those are not good things to have going on. She had just been returned from echo, having undergone a TEE. She was complaining of pain, wanting her pain meds (morphine), wanting to eat, wanting this, that, and the other thing. Dr. came in to evaluate her, and told her she could take out the nasal cannula as long as she stayed above 93 sat.

She took off her NC, and was very irritable. Cranky. So I did what I could for comfort, and took her VS again. HR 67, O2 sat dropped to 89 (so I had her replace the cannula...), no temp, resps at 18. She wanted her morphine. I checked her MAR, she could have it, but...I was uncomfortable giving her morphine w/ her BP so low. I talked to her RN, and her RN said it was my call...so I took it to my professor. His eyebrows went up when I told him her new BP was 92/38, and agreed with me that morphine right now was probably not the best idea. When he went with me to check on her, she was asleep, so we decided to let her sleep while we talked about it.

I told him she was confused, but didn't seem to be in too much pain; no facial grimacing, no muscle guarding, no other indicia that she had pain. I said "I think she's confused, and trying to relieve her anxiety and confusion w/ the morphine." He said that was definitely possible, esp. with the K where it was. He asked me what I thought would be best in the situation, and I said to him 'I think there's something else going on, not just low BP."

I walked him through my rationale - hx of HTN w/ bp the way it was now, 3rd spacing all over, labs wonky, refusing to move off her left side, confusion, the PRBCs yesterday with her platelets now being at 7.3...I told him I thought there was a bleed somewhere. She hadn't lost weight despite being on renal diet and NPO most of the last week (while waiting for the TEE), and she was very fluid-filled in her abdomen. So I figured there had to be a bleed; slow, but still, a bleed. He asked me how the ARF fit in, and I said I thought it was symptomatic of the liver issue, rather than a cause...and that the filtering was overloaded which might account for the high k+ and subsequent confusion, but high K+ could also be from a bleed.

He said "you may be on to something. How about you call the res and see what he thinks?"

I went to call him, but he was on the floor. So I pulled him aside, and asked him if he had r/o a bleed, or if he thought it was something else, and explained I was concerned about giving morphine with her vitals like they were. He asked me to explain why I thought there might be a bleed and why I was reluctant to put morphine on board, and I took him through the same rationale. He didn't say much...but took the chart from me, and went to the phone.

An hour later, I found the new orders...chest and pelvic xray stat r/o effusion in abdominal/thorax, prn haldol, hold morphine.

:) Made me thrilled I was able to get something checked out...I don't know the results, but I do know she was being looked at for 'effusion in abd and thx', and had changed from morphine to haldol. She was taken down to xray about an hour before I went off floor, so like I said, I don't know the results.

I'm tickled...I don't know what the issue is, but I couldn't account for some of the things going on if it wasn't a slow bleed somewhere...and I was thrilled that I was able to put something together and be able to rationalize things for both my professor and the Dr. Dunno if I was right, but it's nice to know my brain is starting to look, assess, put pieces together, and come up with something that other people agreed might be going on.

Just thought I'd share...I am lovin' learning!


Lovin' Learning

tnbutterfly - Mary, BSN, RN

Specializes in Peds, Med-Surg, Disaster Nsg, Parish Nsg.

Great assessment and follow-thru, LovingLearning!!

You might have saved this patient's life. Give yourself a BIG pat on the back.

Let us know the rest of the story.

HouTx, BSN, MSN, EdD

Specializes in Critical Care, Education. Has 35 years experience.


:yeah:You Rock! There are no available statistics on how many patients are saved each year due to a 'highly suspicious' nurse -- but you just joined that group. Patient advocacy is the bedrock of our profession - couple that with an intelligent, educated and inquiring mind and you automatically have the best possible Patient Safety program possible.

Be sure to note this entire anecdote in your own records... and trot it out when it comes time for you to interview for your first job. I am sure that it will impress your future boss just as it has me. :bow:

Tn Butterfly, thank you. I dunno if I was right, but it was enough that the Dr. wrote new orders...addressing all of my concerns (eg the haldol, the effusion...).

Rbezemek, I don't know if I saved her life, but something was going on for sure...and I just couldn't get it out of my head that there was a slow bleed (I kept picturing a balloon slowly deflating...), and tried to account for all aspects of what was going on with her. I even went and spoke to the SN who had her last week about her mental status, and she came over...and then told me that was not the same patient she tended; she was nowhere near as difficult to deal with (the crankiness, the confusion, irritability)...just not the same mental status patient she had last week. That helped me, too...because if this is new, then something 'new' is going on.

If I can find out what happened, I will let you all know...but I have to say it's fun (and a relief) to have the brain finally start making sense of all the stuff I've been shoving in there, you know? LOL.


Lovin' Learning

I am so impressed. Nurse's are supposed to be the patient's advocate and I think your thought process was solid. That has to feel incredibly validating.

Great job!!

:yeah:That's really awesome- good for you! I'm still in my first semester, and I'm nowhere near being able to do that. :bow: I hope that I am able to get to where you are in second semester!

mybrowneyedgirl, BSN, RN

Specializes in Emergency Room.

Good job. Congrats. You're going to be a great nurse. I'm so glad it's all "clicking" for you.

Thanks, you guys...I just feel so good that I can feel this stuff starting to come together. The muddle of first semester, the f/e of second...and all the stuff in between, have managed to find space in this poor brain and come together when I need it to. And that feels sooooo good.


Lovin' Learning

What an excellent experience, beautifully done Lovin' Learning.

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